Regd. Office: 2nd Floor, Training School Complex, Anushaktinagar, Mumbai 400 094
Enrolment Form for Admission to Diploma in Medical Radio Isotope Techniques
(D.M.R.I.T.) / Diploma in Radiological Physics (Dip. R.P.) / Diploma in Fusion Imaging Technology (D.F.I.T.) Programme
Year 20…….-- 20…….
/ Affix recent
self attested
photograph
a. Application No(To be filled by CI)
A / P
/ Enrolment No(To be allotted by HBNI)
b. Constituent Institution(CI) Name
I desire to enroll in HBNI as a regular student to the______programme. My details are as follows:
1. Full Name (as per Standard XII)
(It is mandatory to write name in Hindi also)
2. Date of Birth (DD/MM/YY) /
3. Father/ Mother’s Full Name
4. Address for Correspondence
5. Permanent Address
6. Telephone & Mobile No.
7. Email-ID
8. Category
(General/ SC/ ST/ Others(specify))
9. Nationality
10. Male/ Female
11. Whether Physically/ Visually Challenged (Yes/No, if Yes give details)
12. Educational Qualifications (starting with graduation degree)
Sr.No.
/Degree
/ Year / % Marks / Subjects / University13. Brief Description of work experience of past two years :
Certified that I am not enrolled in any other Programme of any University. The above information furnished by me is true and correct. If any information is found to be incorrect or false, I understand that my admission shall be liable to be summarily terminated without notice.
Date: Signature of the Student
Recommendation by the Designated Authority
Certified that the entries made by the student have been verified from the documents submitted. He/she is eligible for admission to the programme mentioned below as per the relevant ordinance of HBNI.
The said student is recommended for admission in Programme……………
Date: Signature of Designated Authority with stamp**
Verified the application for enrollment and found to be complete with all enclosures.
Date: Dean-Academic (Health Sciences), CI
**1. Head, RMC & Head, RPAD at BARC for DMRIT & DipRP programmes respectively.
2. Director, Academic at TMC for DFIT programme.
To: Dean, HBNI
CHECK-LIST OF MANDATORY ENCLOSURES FOR APPLICANT
The fee (as applicable) to be paid in the form of crossed DD drawn in favour of: “Accounts Officer, HBNI”.
DD No. / Date / Drawn on Bank / Branch / Amount (Rs.)Attached self attested Photocopies of all Mark Sheets, Degree Certificates and Proof of Date of Birth.
Enrolment Form: DMRIT / DipRP / DFIT version 14/11/2013 1/2